PEPTIC ULCER DISEASE

AQEEL ASLAM
Lecturer
College of Pharmacy, UOS
 CONTENTS

DEFINITION AND DESCRIPTION

CLASSIFICATION
SYMPTOMS
CAUSES
RISK FACTORS
COMPLICATIONS
TESTS AND DIAGNOSIS CHART
TREATMENT
LIFE STYLE AND HOME REMEDIES
DEFINITION AND DESCRIPTION

Peptic ulcers are produced by an imbalance between the gastro-

duodenal mucosal defense mechanisms and damaging forces of
gastric acid and pepsin, combined with superimposed injury from
environmental or immunologic agents.

The mucous membrane lining the digestive tract erodes and

causes a gradual breakdown of tissue. This breakdown causes a
gnawing or burning pain in the upper middle part of the belly
(abdomen).
As many as 80% of ulcers are associated with Helicobacter
pylori, a spiral-shaped bacterium that lives in the acidic
environment of the stomach.

Ulcers can also be caused or worsened by drugs such as

aspirin and other NSAIDs.

Although H. pylori infection is usually contracted in childhood,

perhaps through food, water, or close contact with an
infected individual. usually doesn't cause problems in
childhood, if left untreated it can cause gastritis (the irritation
and inflammation of the lining of the stomach), peptic ulcer
disease, and even stomach cancer later in life.
Contrary to general belief, more peptic ulcers arise in the
duodenum (first part of the small intestine, just after the
stomach) than in the stomach.

Duodenal ulcers usually first occur between the ages of 30-50

years and are twice as common in men as in women.

Stomach (or gastric) ulcers usually occur in people older than

60 years and are more common in women.
 Classification
₪Stomach (called gastric ulcer)
₪ Duodenum (called duodenal ulcer)

₪ Oesophagus (called Oesophageal ulcer)

Modified Johnson classification

₪ Type I: Ulcer along the lesser curve of stomach

₪ Type II: Two ulcers present - one gastric, one

duodenal
₪ Type III: Prepyloric ulcer

₪ Type IV: Proximal gastroesophageal ulcer

₪ Type V: Anywhere
SYMPTOMS
Gastric versus duodenal ulcer — Although there is much overlap, symptoms of a
gastric ulcer may be different than those of a duodenal ulcer.

Duodenal ulcer — "Classic" symptoms of a duodenal ulcer include burning,

gnawing, aching, or hunger-like pain, primarily in the upper middle region of the
abdomen below the breastbone (the epigastric region). Pain may occur or worsen
when the stomach is empty, usually two to five hours after a meal. Symptoms may
occur at night between 11 PM and 2 AM, when acid secretion tends to be greatest.
Feel better when you eat or drink and then worse 1 or 2 hours later (duodenal ulcer)

Gastric ulcer — Symptoms of a gastric ulcer typically include pain soon after
eating. Symptoms are sometimes not relieved by eating or taking antacids.
Feel worse when you eat or drink (gastric ulcer)
 SYMPTOMS

Burning pain bloating

Nausea water brash

Unexplained weight loss hematemesis (vomiting of blood)

Appetite changes Melena

vomiting Blood in the stools

Stomach pain wakes you up at night

low blood cell count (anemia)

frequent burping or hiccupping An early sense of fullness with eating

ETIOLOGY AND
PATHOPHYSIOLOGY
Helicobacter pylori infection
 Helicobacter pylori infection

H. pylori is a helix-shaped
¤

¤ Gram-negative, slow-growing organism

¤ about 3 micrometres long with a diameter of about 0.5
micrometres
has 4–6 flagella
¤

¤Helicobacter pylori is composed of a single circular chromosome

with 1,667,867 base pairs, containing about 1590 coding regions
¤It is microaerophilic; that is, it requires oxygen, but at lower
concentration than is found in the atmosphere
¤It contains a hydrogenase which can be used to obtain energy by
oxidizing molecular hydrogen (H2) that is produced by intestinal
bacteria
* It produces oxidase, catalase, and urease

* It is capable of forming biofilms and can convert from spiral

to a possibly viable but nonculturable coccoid form, both
likely to favor its survival and be factors in the epidemiology
of the bacterium.
☻The bacterium persists in the stomach for decades in most
people. Most individuals infected by H. pylori will never
experience clinical symptoms despite having chronic gastritis.
Approximately 10-20% of those colonized by H. pylori will
ultimately develop gastric and duodenal ulcers. H. pylori
infection is also associated with a 1-2% lifetime risk of
stomach cancer and a less than 1% risk of gastric MALT
lymphoma
• Regular use of pain relievers. Nonsteroidal anti-
inflammatory drugs (NSAIDs) can irritate the lining of
stomach and small intestine. These medications, which are
available both by prescription and over-the-counter, include
aspirin, ibuprofen, naproxen, ketoprofen and others. Other
prescription medications that can also lead to ulcers include
medications used to treat osteoporosis called bisphosphonates
(Actonel, Fosamax and others).

• NSAIDs inhibit production of an enzyme (cyclooxygenase)

that produces prostaglandins. These hormone-like substances
help protect stomach lining from chemical and physical injury.
Without this protection, stomach acid can erode the lining,
causing bleeding and ulcers.
♣ Effects of smoking on PUD

♣Increased rate of gastric emptying

♣Diminished pancreatic bicarbonate secretion

♣Decreased duodenal pH

♣
 parasympathetic nerve
increase
NICOTINE activity in
gastrointestinal tract

stimulation to
the enterochromaffin-like cells
and G cells

increases the
amount
of histamine and
gastrin secreted
• Gastrinomas (Zollinger Ellison syndrome), rare gastrin-
secreting tumors, also cause multiple and difficult to
heal ulcers.

• Excessive alcohol consumption Alcohol can irritate and

erode the mucous lining of stomach and increases the amount
of stomach acid that's produced. It's uncertain, however,
whether this alone can progress into an ulcer or if it just
aggravates the symptoms of an existing ulcer.
Caffeine
Beverages and foods that contain caffeine can
stimulate acid secretion in the stomach. This
can aggravate an existing ulcer, but the
stimulation of stomach acid can't be attributed
solely to caffeine.
 Role of Stress
♫ A study of peptic ulcer patients in a Thai hospital showed that chronic stress
was strongly associated with an increased risk of peptic ulcer, and a combination
of chronic stress and irregular mealtimes was a significant risk factor.

♫ An expert panel convened by the Academy of Behavioral Medicine Research

concluded that ulcers are not purely an infectious disease and that psychological
factors do play a significant role. Researchers are examining how stress might
promote H. pylori infection.

♫ For example, Helicobacter pylori thrives in an acidic environment, and stress

has been demonstrated to cause the production of excess stomach acid. This was
supported by a study on mice showing that both long-term water-immersion-
restraint stress and H. pylori infection were independently associated with the
development of peptic ulcers.

♫ Physical stress, is different. It can increase the risk of developing ulcers,

especially in the stomach. Examples of physical stress that can lead to ulcers are
Risk Factors for Ulcers
 You’re at risk for peptic ulcer disease if you:
• Are 50 years old or older.
• Diabetes may increase your risk of having H. pylori
• Drink alcohol excessively.
• Smoke cigarettes or use tobacco.
• Have a family history of ulcer
disease.
• You’re at risk for NSAID-
• induced ulcers if you:
• Are age 60 or older (your stomach lining becomes more fragile with age).
• Have had past experiences with ulcers and internal bleeding
• Take steroid medications, such as prednisone.
 Take blood thinners, such as warfarin.
Consume alcohol or use tobacco on a regular
• basis.
• Experience certain side effects after taking NSAIDs, such as upset stomach
• and heartburn.
• Take NSAIDs in amounts higher than recommended
Take NSAIDs for long periods of time
 Stress does not cause an ulcer, but may be a
contributing factor
COMPLICATIONS
Ж Gastrointestinal bleeding is the most common
complication. Sudden large bleeding can be life-
threatening. It occurs when the ulcer erodes one of the
blood vessels. Bleeding can occur as slow blood loss that
leads to anemia or as severe blood loss that may require
hospitalization or a blood transfusion.

ж Perforation (a hole in the wall) often leads to catastrophic

consequences. Erosion of the gastro- intestinal wall by the
ulcer leads to spillage of stomach or intestinal content into
the abdominal cavity. Perforation at the anterior surface of
the stomach leads to acute peritonitis, initially chemical and
later bacterial peritonitis. The first sign is often sudden
intense abdominal pain. Posterior wall perforation leads to
pancreatitis; pain in this situation often radiates to the back.
ж Penetration is when the ulcer continues into
adjacent organs such as the liver and pancreas.

ж Scar tissue Scarring and swelling due to ulcers

causes narrowing in the duodenum and gastric
outlet obstruction. Patient often presents with
severe vomiting. Peptic ulcers can also produce
scar tissue that can obstruct passage of food
through the digestive tract, causing you to become
full easily, to vomit and to lose weight.
 WARNING SIGNS

vomit blood sudden, severe pain

vomit food eaten hours or ongoing nausea or

repeated
days before
vomiting.

feel unusually weak or

feel cold or clammy
dizzy

pain doesn't go away

blood in your stools losing weight
With medication
TESTS AND DIAGNOSIS CHART
 Noninvasive

Urea Breath Test (UBT) Blood test

Invasive

Histology Biopsy Urease Test

 Culture

Other tests Stool antigen test

Endoscopy

Upper gastrointestinal (upper GI) X-ray

TREATMENT
GOALS

☻ lowering the amount of acid that stomach makes,

☻neutralizing the acid

☻ protecting the injured area so it can heal

☻ It's also very important to stop smoking and drinking alcohol

☻Prevent complications (bleeding, perforation, penetration,

obstruction)

☻Minimize recurrences
Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori
because one antibiotic alone isn't always sufficient to kill the organism. Antibiotics
prescribed for treatment of H. pylori include amoxicillin, clarithromycin and
metronidazole. Combination drugs that include two antibiotics together with an acid
suppressor or cytoprotective agent have been designed specifically for the treatment of
H. pylori infection.
Acid blockers. Acid blockers — also called histamine (H2) blockers — reduce the
amount of hydrochloric acid released into digestive tract, which relieves ulcer pain and
encourages healing. Acid blockers work by keeping histamine from reaching histamine
receptors. Histamine is a substance normally present in body. When it reacts with
histamine receptors, the receptors signal acid-secreting cells in stomach to release
hydrochloric acid. Available by prescription or over-the-counter, acid blockers include
the medications ranitidine, famotidine, cimetidine and nizatidine.
Antacids. An antacid may be taken in addition to an acid blocker or in place of one.
Instead of reducing acid secretion, antacids neutralize existing stomach acid and can
provide rapid pain relief.
Proton pump inhibitors. Another way to reduce stomach acid is to shut down the
"pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by blocking
the action of these tiny pumps. These drugs include the prescription and over-the-
counter medications omeprazole, lansoprazole, rabeprazole and esomeprazole.
Doctors frequently prescribe proton pump inhibitors to promote the healing of peptic
ulcers. Proton pump inhibitors also appear to inhibit H. pylori.
Cytoprotective agents. In some cases, your doctor may prescribe these medications
that help protect the tissues that line your stomach and small intestine. They include the
prescription medications sucralfate and misoprostol. Another nonprescription
cytoprotective agent is bismuth subsalicylate.
Bowel rest: Bed rest and clear fluids with no food at all for a few days. This gives the
ulcer a chance to start healing without being irritated.
Nasogastric tube: Placement of a thin, flexible tube through your nose and down into
your stomach. This also relieves pressure on the stomach and helps it heal.
Urgent endoscopy or surgery if indicated: Damaged, bleeding blood vessels can
usually be repaired with an endoscope. The endoscope has a small heating device on
the end that is used to cauterize a small wound.
 Surgery

Vagotomy Antrectomy Tying off an

Pyloroplasty
artery

Other modes
Of
treatment

Acupuncture Chiropractic Homeopathy Herbs

LIFE STYLE AND HOME REMEDIES
 Use of Olive Oil

Limit or avoid alcohol

Less Avoid nonsteroidal

Coffee anti-
Caffeinated inflammatory
Beverages drugs (NSAIDs)

Exercise

Fruits and Stress Relief

Vegetables